Jason Q. Purnell

Prevalence, Demographics, and Psychological Associations of Sleep Disruption in Patients With Cancer: University of Rochester Cancer Center―Community Clinical Oncology Program

PURPOSE Sleep disruption is prevalent in patients with cancer and survivors, but the prevalence of insomnia, a distressing sleep disorder, in these populations has yet to be determined in large-scale studies. PATIENTS AND METHODS A total of 823 patients with cancer receiving chemotherapy (mean age, 58 years; 597 female patients) reported on sleep difficulties in a prospective study. RESULTS During day 7 of cycle 1 of chemotherapy, 36.6% (n = 301) of the patients with cancer reported insomnia symptoms, and 43% (n = 362) met the diagnostic criteria for insomnia syndrome. Patients with cancer younger than 58 years were significantly more likely to experience either symptoms of insomnia or insomnia syndrome (chi(2) = 13.6; P = .0002). Patients with breast cancer had the highest number of overall insomnia complaints. A significant positive association was found between symptoms of insomnia during cycles 1 and 2 of chemotherapy (phi = .62, P < .0001), showing persistence of insomnia during the first two cycles of chemotherapy. Sixty percent of the patient sample reported that their insomnia symptoms remained unchanged from cycle 1 to cycle 2. Those with insomnia complaints had significantly more depression and fatigue than good sleepers (all P < .0001). CONCLUSION The proportions of patients with cancer in this sample reporting symptoms of insomnia and meeting diagnostic criteria for insomnia syndrome during chemotherapy are approximately three times higher than the proportions reported in the general population. Insomnia complaints persist throughout the second chemotherapy cycle for the majority of patients with cancer in this study. Insomnia is prevalent, underrecognized, undermanaged, and understudied among patients with cancer receiving chemotherapy.

Information-Seeking Styles Among Cancer Patients Before and After Treatment by Demographics and Use of Information Sources

The type and quantity of information needed varies between patients who actively seek information and those who tend to avoid information.We analyzed data from a longitudinal study of adult cancer patients from outpatient clinics for whom information needs and behaviors were assessed by survey before and after treatment. We evaluated the relationships between information-seeking style (active, moderately active, and passive styles) and demographics, cancer type, and health status for the pretreatment and posttreatment periods and overall. The generalized estimating equations (GEE) approach was used to model the log odds of more active to more passive information-seeking preferences taking into consideration both the pretreatment and posttreatment periods. Analyses included 731 case participants, including female breast cancer patients (51%), male genitourinary cancer patients (18%), and lung cancer patients of both sexes (10%). At pretreatment, 17% reported an active information-seeking style, 69% were moderately active, and 14% were passive. During this period, 19% of those with at least some college education reported being very active compared with 14% of those with less education. With adjustment for all other covariates, male genitourinary and lung cancer patients had a higher odds of having a more active information-seeking style in the pretreatment than in the posttreatment period, with an odds of 4.5 (95% confidence interval [CI]: 2.4–8.4) and 5.4 (95% CI: 2.7–10.6), respectively. Controlling for all covariates, breast cancer patients had 1.5 (95% CI: 1.0–2.1) times higher odds of being more active in seeking information than other patients. Public health researchers and clinicians must work together to develop the most effective strategy for meeting the informational needs of these patients before and after treatment.

Perceived Discrimination, Psychological Distress, and Current Smoking Status: Results From the Behavioral Risk Factor Surveillance System Reactions to Race Module, 2004–2008

OBJECTIVES We examined the association between perceived discrimination and smoking status and whether psychological distress mediated this relationship in a large, multiethnic sample. METHODS We used 2004 through 2008 data from the Behavioral Risk Factor Surveillance System Reactions to Race module to conduct multivariate logistic regression analyses and tests of mediation examining associations between perceived discrimination in health care and workplace settings, psychological distress, and current smoking status. RESULTS Regardless of race/ethnicity, perceived discrimination was associated with increased odds of current smoking. Psychological distress was also a significant mediator of the discrimination-smoking association. CONCLUSIONS Our results indicate that individuals who report discriminatory treatment in multiple domains may be more likely to smoke, in part, because of the psychological distress associated with such treatment.

Effects of a Structured Weight-Bearing Exercise Program on Bone Metabolism Among Breast Cancer Survivors: A Feasibility Trial

PURPOSE Treatments for breast cancer, specifically hormonal therapy, accelerate bone loss (BL) among breast cancer survivors, leading to osteoporosis and an increase in fracture risk. Tai Chi Chuan (TCC) is a moderate form of weight-bearing exercise, equivalent to walking, and it has been shown to improve aerobic capacity and strength among breast cancer survivors and might also be effective in slowing bone loss in breast cancer survivors. This pilot study compared the influence of TCC with that of standard support therapy (ST; exercise control) on BL biomarkers among breast cancer survivors. PATIENTS AND METHODS Randomly assigned breast cancer survivors (N = 16; median age, 53 years; < 30 months after treatment) completed 12 weeks (3 times per week, 60 minutes per session) of TCC or ST. Serum levels of N-telopeptides of type I collagen (NTx), a marker of bone resorption, and bone-specific alkaline phosphatase (BSAP), a marker of bone formation, were determined according to enzyme-linked immunosorbent assay at baseline and after the intervention. RESULTS Using analysis of covariance, survivors in the TCC group experienced a greater increase in levels of bone formation (BSAP [microg/L]: before, 8.3; after, 10.2; change, 1.9 microg/L and 22.4%), compared with survivors in ST (BSAP [microg/L]: before, 7.6; after, 8.1; change, 0.5 microg/L [6.3%]). Survivors in the TCC group also experienced a significant decrease in bone resorption (NTx [nanomoles bone collagen equivalent; nmBCE]: before, 17.6; after, 11.1; change, -6.5 nmBCE; -36.9%), whereas women in the ST group did not (NTx [nmBCE]: before, 20.8; after, 18.8; change, -2.0 nmBCE; -9.6%). CONCLUSION This pilot study suggests that weight-bearing exercise exerts positive effects on BL, through increased bone formation and decreased bone resorption. Further examinations of the influence of TCC on bone health are warranted.

What are successful recruitment and retention strategies for underserved populations? Examining physical activity interventions in primary care and community settings

The purposes of this review are to (1) describe recruitment and retention strategies for physical activity interventions focusing on underserved populations and (2) identify successful strategies which show the most promise for “best practices” recommendations to guide future research. The method used was systematic review. Data on recruitment and retention strategies were abstracted and analyzed according to participant characteristics, types of strategies used, and effectiveness using an ecological framework. Thirty-eight studies were identified. Populations included African American (n = 25), Hispanic (n = 8), or Asian (n = 3) groups. Successful recruitment strategies consisted of partnering with respected community stakeholders and organizations, well-trained study staff ethnically, linguistically, and culturally matched to the population of interest, and use of multiple advertising channels. Successful retention strategies included efficient administrative tracking of participants, persistence, skillful teamwork, and demonstrating a positive, caring attitude towards participants. Promising recruitment and retention strategies correspond to all levels of ecological influence: individual, interpersonal, organizational, and societal.

Translating Evidence into Population Health Improvement: Strategies and Barriers

Among the challenges facing research translation-the effort to move evidence into policy and practice-is that key questions chosen by investigators and funders may not always align with the information priorities of decision makers, nor are the findings always presented in a form that is useful for or relevant to the decisions at hand. This disconnect is a problem particularly for population health, where the change agents who can make the biggest difference in improving health behaviors and social and environmental conditions are generally nonscientists outside of the health professions. To persuade an audience that does not read scientific journals, strong science may not be enough to elicit change. Achieving influence in population health often requires four ingredients for success: research that is responsive to user needs, an understanding of the decision-making environment, effective stakeholder engagement, and strategic communication. This article reviews the principles and provides examples from a national and local initiative.

Use of cancer control referrals by 2-1-1 callers: a randomized trial.

BACKGROUND Callers to 2-1-1 have greater need for and lesser use of cancer control services than other Americans. Integrating cancer risk assessment and referrals to preventive services into 2-1-1 systems is both feasible and acceptable to callers. PURPOSE To determine whether callers will act on these referrals. METHODS In a randomized trial, 2-1-1 callers (n=1200) received standard service and those with at least one cancer risk factor or need for screening were assigned to receive verbal referrals only, verbal referrals + a tailored reminder mailed to their home, or verbal referrals + a telephone health coach/navigator. All data were collected from June 2010 to March 2012 and analyzed in March and April 2012. RESULTS At 1-month follow-up, callers in the navigator condition were more likely to report having contacted a cancer control referral than those receiving tailored reminders or verbal referrals only (34% vs 24% vs 18%, respectively; n=772, p<0.0001). Compared to verbal referrals only, navigators were particularly effective in getting 2-1-1 callers to contact providers for mammograms (OR=2.10, 95% CI=1.04, 4.22); Paps (OR=2.98, 95% CI=1.18, 7.54); and smoking cessation (OR=2.07, 95% CI=1.14, 3.74). CONCLUSIONS Given the extensive reach of 2-1-1s and the elevated risk profile of their callers, even modest response rates could have meaningful impact on population health if proactive health referrals were implemented nationally.

The efficacy of calcitriol therapy in the management of bone loss and fractures: a qualitative review

SummaryOsteoporosis, a skeletal disorder characterized by a reduction in bone strength, increases fracture risk. Primary osteoporosis is usually a result of reduced bone mineral density as a consequence of natural aging. Secondary osteoporosis is usually a result of a disease, such as cystic fibrosis, or medical treatment, such as corticosteroids or cancer treatment.IntroductionCurrently, ten million Americans are osteoporotic and an additional 34 million have the precursor condition, osteopenia. Osteoporosis leads to 1.5 million fractures and 500,000 hospitalizations annually. Osteoporosis-related fractures increase mortality and reduce quality of life. Calcitriol, the active form of vitamin D, regulates intestinal calcium absorption, among other actions. During the past four decades, many clinical trials investigating the effect of calcitriol on bone loss have been performed.MethodsWe conducted a systematic qualitative review of clinical trials that assessed calcitriol for the treatment of osteoporosis and bone loss. In these clinical trials, calcitriol was used as a monotherapy and in combination with other therapeutic bone agents.Results and conclusionStudies using calcitriol monotherapy, although not conclusive, found that calcitriol slowed the rate of bone loss in a variety of populations. Calcitriol in combination with other therapeutic bone agents was shown to have additional bone-preserving effects when compared to the use of therapeutic bone agents alone. A common side-effect of calcitriol therapy was hypercalcemia and hypercalciuria, but the degree of hypercalcemia was mild. Recent research found that intermittent dosing can reduce hypercalcemia rates. Calcitriol, alone or in combination with other agents, should be considered for the therapy of osteoporosis.

Friendships of Children and Adolescents With Spina Bifida: Social Adjustment, Social Performance, and Social Skills

OBJECTIVE To characterize dyadic and general friendships of youth with spina bifida (SB). METHODS Families of youth with SB recruited a peer to participate; 106 dyads participated. Youth with SB and peers completed questionnaires and interviews regarding characteristics of the dyadic friendship and each individuals general friendships. RESULTS Youth with SB and their peers were similar in many ways. However, youth with SB rated the friendship as closer and were more likely to see peers as best friends rather than the reverse. Regarding general friendships, youth with SB spent fewer days with friends, reported lower levels of companionship, security, and closeness in their friendships, and reported lower levels of emotional support from peers and family. CONCLUSIONS Youth with SB experience significant differences in the quality and reciprocation of friendships. Targeted interventions may assist youth in developing high quality friendships.

The Good Life Working Together to Promote Opportunity and Improve Population Health and Well-being

Lifeexpectancy is loweranddiseasemorbidity ishigher in the United States than in other high-income countries.1 This situation, decades old, is not for lack of skilled medical care; the United States has among the world’s best hospitals and technology. Nor is spending on health care inadequate; per capita health expenditures in the United States far exceedspendingelsewhere.Thepoorerhealthof racialandethnicminorities does not explain the nation’s low rankings; the US non-Hispanic white population and other advantaged groups also have worse health outcomes than their peers in other countries.1,2 TheUShealth care systemcertainlyhasdeficiencies,notably the lackofuniversal coverage,but this alone does not explain the pervasive health disadvantage. Health is aboutmore thanhealth care,withhealth care accounting for only an estimated 10% to 20% of health outcomes. As reported in JAMA 23 years ago, the nation’s major diseases havemore to dowith unhealthful behaviors—for example, smoking—than health care.3 Overenthusiastic advocates of personal responsibility, however, often blame poor health entirely on individuals and their imprudent habits. Behaviors are notoriously difficult to change, even among the affluent, and they are often influenced by environmental factors beyond personal control. This is especially true in low-income communities, where healthful food, parks, sidewalks, playgrounds, and physicians are often scarce. The socioecologicalmodel of health recognizes that proximal health determinants such as medical care and individual behaviors are influencedbysocioeconomic circumstancesand the environment, all of which are shaped by macrostructural factors suchaspublic policies.4 Foremost among the social determinantsofhealth is education,whichprovidesapath toemployment, income, and the skills for social mobility. Collegeeducated adults have substantially lowerdisease rates thando thosewithout a high school diploma.5 Although these disparitiesprobablyhavemore todowith incomethandiplomas,data about the income-health gradient aremore limited. Income is a sensitive topic for surveys to explore and, unlike education, is not recorded on death certificates (and thus vital statistics). In this issue of JAMA, an important study by Chetty and colleagues6shedsnewlightontherelationshipbetweenincome andlifeexpectancy.Usinginnovativedatasources(taxandSocial Securityrecords), theauthorshaveelucidatedthestructuralform of the relationship and unearthed fascinating details about its evolutionovertimeandacrosscommunities.Forexample,based onpooleddatafrom2001through2014, theycalculatedthat the gap in lifeexpectancyfor therichestandpoorest 1%of individualswas 14.6years formenand10.1years forwomen.Lifeexpectancy, and its changes during these years, varied substantially by region. The study only examined life expectancy at age 40 yearsby incomepercentile; lifeexpectancyatbirth, themorefamiliar statistic,may be affected differently by income. The authorsalsoexcludedpeoplewithnoincome.Althoughtheincomehealthrelationship ismediatedbyneighborhoodconditions, the authors limited their analysis tobroadgeographic areas (aggregationsof counties). Their article reported trendsonly for areas with more than 590000 persons, thus excluding some rural areas,buttheir findingsfor100populatedlocalities isagreatservice to local leaders and residents. The studycouldnotbemore timely.Medianhousehold income in theUnitedStateshasbeenstagnant for2decades, aperiodwhenwealth shifteddramatically to theupper class.7Wideningincomeinequalityandtheendangeredmiddleclassarenow topics of public discourse.Meanwhile, thepublic health literaturehasdocumentedasteepeninghealthgradientbasedonsocioeconomic status.8 The adverse consequences of having low educationandincomehaveintensified.5Lifeexpectancyhasdecreased forwhitesof lowsocioeconomic status.9,10Chettyet al confirmthisdisturbingpattern,reportingthatthehighest-income quartile enjoyed the greatest gains in life expectancy between 2001and2014,whilethelowest-incomequartilesawsmallgains in lifeexpectancy.Theyreported that lifeexpectancy increased by2.3years formenand2.9years forwomeninthetop5%ofthe incomedistributionbut increasedbyonly0.3years formenand 0.04 years for women in the bottom 5%. Life expectancy decreasedincertainstatesandcities.Thehealthimplicationsofthis trend are concerning, especially at a timewhen the number of financially stressed households is increasing. Opportunity—the chance to thrive in health and other aspirations—is unevenly distributed across society. Due to structural changes in theeconomyand the legacyofbiasedpolicies, the poor and people of color face greater barriers to education and economic opportunity. Racial disparities in income are dwarfed by disparities inwealth (eg, assets, net worth), which may be an even stronger health determinant. The networth of whites is more than 15 times that of blacks (